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0003-007 (BLCK)F= N_ LU O � M W dZ" �0o H(D ILL! UJ N Z Cl) L0 N O0) U Q It CL Z LO a 0 XW 0-'Q M U U O CL: rnH lcd- Z Cb Z—) Q J LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date Date Signature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: I, as owner of the property, or my employees with wages as their sole ompensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business & Professionals Code). ( ) I; as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). () I am exempt under Section , B&P. Cfor this reason Date. "1 -.`' Signature of Owner �r 1♦ 4, k r i 1 WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ( ) I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ( ) I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier & policy no. are: Carrier Policy No. (This section need not be completed if the permit valuation is for $100.00 or less). (e)71 certify that in the performance of the work for which this permit is issued, I/shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code,..I,shall forthwith comply with those provisions. Date: 1 — /'! (Applicant \� lr t V\", `, Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application -and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property _foorr inspection purposes. Signature (Owner/Agent) 1 :� )►'`�Date "' _11,v BUILDING PERMIT PERMIT04110. $07 DATE VALUATION 51,903.00 LOT TRACT JOBSITE ~2375A%' r-IIL)Ars Rtil(Ji)iAS APN ADDRESS OWNER CONTRACTOR/DESIGNER/ENGINEER NEt1L IARRE'.11' ow"NERIBUI'LUCI 52375 �.VENIDA BERMUDAS 52-3715 AVEN.IDA BElt,tl MAS .LA QUINTA CA 92253 LA QUOITA CA 9225: USE OF PERMIT C;ENFI, WIJNG SUPP.Lrwi II.:I3I ail. d'OPUM1 Utf 60772 L.tr. C(H) / 20 L.F. s'trll/�IuL. t . 3 (11)(0gW..EN WALL - t;lT S ANUARU S 1 T . WAU 55.00 L d .%I'. MALL 3 + c,}ti d..F M'1 TIMATE" CONT 01i' 1."GdSTRIJI;."tdON' 1,903.n. PERMIT FEE SUMMARY . CoN3iituc."Cft, N FT -;E 101-OGU-418-000 �15.(>•� S(7R3_TO'I ,AL1, C ON,"Tr R ( MrION A N1) PU\`}V C'H ;C,K � $45.00 LES ti 111U2-R,1UD J -TES n, ,. o 1AMA-11 V1411R.n111rr 141FIES apt) E Niaw S45.01) RECEIPT DATE BY/ tV/ r . INSPECTOR ME :�j INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel. Combustion Air Roof Deck Exhaust Fans O.K. to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.Q. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs Electric Bond _-7 Footings Main Drain Bond Beam 3 //� % O 7 Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final l Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsula(ion Gas Piping Gas Test Appliances Final Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: L A7- VA LL � - 7s � A C-40 zxc- P A Al -4 4•� 9,4 13 DEPARTMENT OF BUILDING i SAFETY COUNTY OF RIVERSIDE 71 CONSTRUCTION ESTIMATE S NO. ELECTRICAL FEES NO. PLUMBING FEES IST FL. SO. FT. 0 2ND FL. ` SO. FT. 0 POR80 FT GAR. SO. FT. 0 CAR P. 80. FT. 0 WALL 80. FT. 0 SO, FT, 0 ESTIMATED CONSTRUCTION VALUATION S 01Z)YARD �) t y dO UNITS MOBILENOME SVC. POWER OUTLET SPKLR SYSTEM BAR SINK ROOF DRAINS DRAINAGE PIPING DRINKING FOUNTAIN URINAL WATER PIPING NOTE: Not to be used as property tax valuation S -j 14 ❑ LAND USE FLOOR DRAIN MECHANICAL FEES S 2 WATER SOFTENER VENTSYSTEM FAN EVAP.COOL HOOD _ SIGN WASHER(AUTOXDISH) APPUANCE DRYER 1 S GARBAGE DISPOSAL FUPJ"C'.E UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY AIR HANDLING UINR CFM IDTCHEN SINK ABSORPTION SYSTEM B.T.U. TEMPU SE PERMIT 8VC WATER CLOSET COMPRESSOR HP POLE,TEMIPERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. SO. FT 0 s BATH TUB SO. FT. 0 s WATER HEATER MAX HEATER OUTPUT, B.T.U. SO.FT.RESID 011Ue SEWAGE DISPOSAL i SO.FT.GAR 490 HOUSE SEWER GAS PIPING PERMIT FEE PERMIT FEE LO PERMIT FEE ELUMBFEE DBL TOTAL FEES MICRO FEE MECH. FEE PL CK. FEE CONST. FEE ELECT. FEE SMI FEE MICRO FLLM FEE Cops S NECK FEE Dbl S ❑ OtADOG M CK. FEE ❑ ROAD DEPT S it'r LL CONS RUCTM PEE Dw S -j 14 ❑ LAND USE ELECTRICAL FEE Obl S 2 SMI FEE I _ G PLUMBING FEE Dbl 1 S TOTAL FEES IS M.O. 0 N.C. CASH ❑ CHECK RECOYED Br TIN ES REQUIRED SEWAQC SrtTEM T LL P IIIEWER DISTRICT FORM 2&'38 (REV. N79) JOB ADDRESS USE OF PERMIT PIP UU 5 LrOfe) PLAN NO. PLAN CHECKER DATE NOT APPROVED COMMUNITY VALUATION DATE DATE APPROVED OWNER TA th4 F.C.C. GROUP SUPP. TO PERMIT PLAN CLEARANCEIIEO'D CHECK ❑ OtADOG PLUMBING ❑ ROAD DEPT ❑ HEALTH DEPT ELECTRICAL ❑ PLANNING DEPT ❑ LAND USE STRUCTURAL FIRE MARSHAL AUDIT I C.R.T. REMARKS.